Aortoesophageal fistula: case report and review of the literature

Abstract

Aortoesophageal fistula is a rare but fatal cause of upper gastrointestinal bleeding. The classic clinical triad consists of midthoracic pain or dysphagia, a sentinel episode of hematemesis, followed by fatal exsanguination. In a patient with hemodynamically significant upper gastrointestinal bleeding of unknown etiology, who has evidence of a tortuous aorta or aneurysm by chest x-ray or who exhibits Chiari's triad, the presence of AEF should be entertained. A prompt and definitive diagnosis at the time of the initial hemorrhage is necessary for a successful surgical outcome. Cautious endoscopy to exclude other causes of bleeding followed by either thoracic CT scan or thoracic aortography are indicated based on circumstances. We report a case of a 76-year-old man who presented with two discrete episodes of hemodynamically significant upper gastrointestinal bleeding. Although there was no radiological evidence of an aneurysm on chest x-ray and no endoscopic evidence of an aortoesophageal fistula, a saccular descending thoracic aorta aneurysm was found by thoracic aortogram. The patient underwent immediate surgical repair of the aorta by graft and esophagectomy, followed by a staged gastric pull-up. Left thoracotomy with fistula repair is the only definitive treatment for AEF. Use of a Sengstaken-Blakemore tube or embolization of the fistula prior to surgery should be considered only if the patient is exsanguinating. Although surgical repairs have high morbidity and mortality, surgery should be undertaken, as untreated cases of AEF are uniformly fatal.